In this issue, Zhao et al. investigate the effects of subclinical hypothyroidism in coronary bypass grafting particularly with respect to the incidence of atrial fibrillation. While not the first of its kind, the authors analyze this controversial topic in a well powered, statistically comprehensive manner that furthers our understanding of the effects of SCH in CABG patients.
Improving clinical practice in ENT: lessons learnt from the COVID-19 pandemicJames R Tysome, Cambridge University Hospitals, UKEditor-in-Chief, Clinical OtolaryngologyWhile currently in the midst of another wave of COVID-19 infections, putting untold strain on both healthcare systems and healthcare workers around the globe, it is important to reflect on the changes that we have all had to make. All ENT departments, within a very short timeframe, restructured clinical services to prioritise the delivery of patient care to those with the greatest clinical need, while increasing services such as tracheostomy for the high number of patients with COVID-19 in intensive care. We also changed the methods that we use to teach our trainees and share knowledge with colleagues. Many of these changes have been successful and should now be maintained in the future.It has been fascinating to see the how the research community built new research networks and redirected focus to projects related to understanding SARS-CoV-2 infection; surveillance and public health measures, optimising patient management of the disease and understanding the impact of COVID-19 on different healthcare systems. This resulted in over 89,000 peer reviewed publications relating to COVID-19 in 2020 and the development of new research structures such as CovidSurg , a global collaborative platform of studies aiming to explore the impact of COVID-19 on surgical patients.1Two papers in this issue demonstrate how clinical practice in ENT adapted to COVID-19. The first explores the publication of guidance relevant to ENT.2 Both national bodies and specialist societies across the globe published guidance on how services should be reconfigured, patients prioritised, and ENT surgeons protected, particularly with respect to aerosol generating procedures given the potential high risk of infection. It is the speed of publication that was particularly impressive. Of the 175 online publications of COVID guidance related to ENT, 41% were published between the third and fourth week of March 2020.The second study explores the impact of this guidance on clinical care through a prospective audit of the management of tonsillitis and peritonsillar abscess in 86 hospitals across the UK following the publication of guidelines by ENT UK, the professional body representing ENT surgeons in the UK. This provided a pathway that aimed to prevent hospital admission when safe to do so.3 Increased use of single doses of intravenous dexamethasone and antibiotics resulted in return to swallowing in many patients, allowing patients to be discharged safely, without later increases in re-presentation or admission.These studies show the strong clinical leadership has been demonstrated within the ENT community, removing traditional barriers to change. Clinicians have taken the initiative to develop new pathways and new ways of working. An almost overnight change from face-to-face appointments to remote appointments took place in many hospitals, showing how we can adapt when needed. Remote appointments, either by telephone4 or video calls,5 are suitable for many ENT patients, preferred by many and are certainly here to stay.There has been rapid scaling of technology such as digital consultation platforms to enable this remote service delivery. Video conferencing facilitates multidisciplinary team meetings, bringing together clinicians at distant locations to discuss patient management in an efficient manner without the need to spend hours travelling to meet in the same location. Virtual patient consultations can allow sharing of digital information such as imaging without the patient needing to leave their home, reduced footfall in previously over-crowded outpatient departments.New teaching and training opportunities have arisen through the use of digital conferencing platforms, replacing traditional teaching programmes and allowing us to reach larger audiences.6Entire conferences have successfully moved to virtual participation. These opportunities have the potential to significantly enrich training and teaching in the future.We have seen many examples of enhanced local system working. ENT and intensive care teams have needed to work more closely together to manage patients with COVID-19 requiring a tracheostomy.7 It is important that these closer relationships are maintained in the future for patient benefit.The ENT community has demonstrated strong clinical leadership, adaptability to rapid change, enhanced clinical pathways and local networks, widespread use of digital technology for consultation and teaching and redirection of research programmes. These have permanently changed the way we work and, when the current global pandemic improves as COVID-19 infections drop and vaccination programmes are rolled out, we should ensure that the positive changes that have been made are embedded in clinical practice to improve patient care.Globalsurg.org. Covidsurg, NIHR Global Health Research Unit on Global Surgery [Cited 2020 Jan 18]. Available from https://globalsurg.org/covidsurg/Cernei st al. Timing and volume of information produced for the Otolaryngologist during the COVID-19 pandemic in the UK. A review of the volume of online literature. Clin Otolaryngol;46(2):???????Smith M, et al. Admission avoidance in tonsillitis and peritonsillar abscess: a prospective national audit during the initial peak of the COVID-19 pandemic. Clin Otolaryngol;46(2):???????Sharma S and Daniel M. Telepmedicine in paediatric otorhinolaryngology: lessons learnt from remote encounters during the COVID19 pandemic and implications for future practice. Int J Paediatr Otorhinolaryngol. 2020:139:110411.Fieux M, et al. Telemedicine for ENT: effect on quality of care during COVID-19 pandemic. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137(4):257-261.Herman A, et al. National, virtual otolaryngology training day in the United Kingdom during the COIVD-19 pandemic: results of a pilot survey. J Surg Educ. 2020; S1931-7204McGrath BA, et al. Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP). Anaesthesia 2020;75(12):1659-1670.
Global influenza virus circulation declined and has been below traditional seasonal levels during the COVID-19 pandemic.1-3 We reviewed WHO influenza surveillance outputs from May 1-December 31, 2020 (epidemiologic weeks 18-53) from tropical Asian countries. For each country we report influenza surveillance specimens tested, and the percentage positive for influenza, by type and subtype. We compared current data to historical data from 2015-2019 in order to place the current season in historical context. Twelve included countries tested 17,407 surveillance specimens, with 592 (3.4%) testing positive for influenza viruses. From April 27-July 26, 2020 (epidemiologic weeks 18-30), specimens tested decreased from an average of 14,102 per year in 2015-2019 to 3,969 (71.9% decrease) and influenza positivity from 22% to <1%. During weeks 31-53, specimens tested decreased from an average of 24,782 per year in 2015-2019 to 13,438 (45.8% decrease) and influenza positivity from 18% to 4%. In six countries that maintained testing of surveillance specimens for >90% of weeks, influenza circulation was unseasonably low, or absent, during weeks 18-30, 2020. However, during weeks 31-53, the percentage of surveillance specimens testing positive for influenza approached or reached positivity rates of 2015-2019 in Bangladesh and Cambodia; and increased but remained lower than historical positivity in Lao PDR and Viet Nam. The data presented here are a reminder that the low levels of influenza circulation in the northern hemisphere in summer 2020 may not necessarily persist into the upcoming influenza season, and influenza surveillance and prevention strategies should continue as planned and not be delayed.
Background: The success of coronary artery bypass grafting surgery (CABG) is dependent on long-term graft patency, which is negatively related to early wall thickening. Avoiding high-pressure distension testing for leaks and preserving the surrounding pedicle of fat and adventitia during vein harvesting may reduce wall thickening. Methods: A single-centre, factorial randomised controlled trial was carried out to compare the impact of testing for leaks under high versus low pressure and harvesting the vein with versus without the pedicle in patients undergoing CABG. The primary outcomes were graft wall thickness, as indicator of medial-intimal hyperplasia, and lumen diameter assessed using intravascular ultrasound after 12 months. Results: 96 eligible participants were recruited. With conventional harvest, low-pressure testing tended to yield a thinner vessel wall compared to high-pressure (mean difference MD (low minus high) -0.059mm, 95%CI -0.12, +0.0039, p=0.066). With high pressure testing, veins harvested with the pedicle fat tended to have a thinner vessel wall than those harvested conventionally (MD (pedicle minus conventional) -0.057mm, 95%CI -0.12, +0.0037, p=0.066, test for interaction p=0.07). Lumen diameter was similar across groups (harvest comparison p=0.81; pressure comparison p=0.24). Low pressure testing was associated with fewer hospital admissions in the 12 months following surgery (p=0.0008). Harvesting the vein with the pedicle fat was associated with more complications during the index admission (p=0.0041). Conclusions: Conventional saphenous vein graft preparation with low pressure distension and harvesting the vein with a surrounding pedicle yielded similar graft wall thickness after 12 months, but low pressure was associated with fewer adverse events.
Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.
If it an’t broke, don’t fix itBerhane Worku MD1, Meghann M Fitzgerald21: Department of Cardiothoracic Surgery, Weill Cornell Medical College2. Department of Anesthesiology, Weill Cornell Medical CollegeAntifibrinolytics and TEGCorresponding Author:Berhane WorkuDepartment of Cardiothoracic SurgeryWeill Cornell Medical College525 East 68th Street M-404New York, NY 10065Despite evidence of associated morbidity and mortality, blood products are administered to over half of cardiac surgical patients, accounting for approximately 20% of their worldwide use1,2. These statistics attest to the ubiquitous and refractory nature of bleeding after cardiac surgery. In an attempt to curb the excessive use of blood products after cardiac surgery viscoelastic testing in the form of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been increasingly utilized. Rapid intraoperative assessment allows for targeted correction of coagulopathy due to residual heparinization, coagulation factor deficiency, hypofibrinogenemia, and platelet dysfunction. Hyperfibrinolysis can also be assessed, although management is rarely altered as the routine administration of lysine analog antifibrinolytics has been given a class I recommendation by the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists and has become the standard practice at most cardiac surgical centers.Cardiopulmonary bypass is known to result in transient t-PA and subsequent d-dimer level elevations (a marker of hyperfibrinolysis)3,4. The efficacy of the lysine analog antifibrinolytics, tranexamic acid andε-aminocaproic acid, have been extensively studied in this setting. D-dimer levels are significantly blunted by antifibrinolytics, and an abundance of literature demonstrates reductions in chest tube bleeding, blood product use, and reoperation for bleeding with the use of these agents4-6. A similar amount of evidence points to their safety, with no increase in thrombotic complications, including stroke, myocardial infarction, graft closure, or mortality seen5-7. A higher risk of seizures is noted with tranexamic acid, although this appears to be dose dependent and nonexistent with ε-aminocaproic acid2. If the ultimate goal is to reduce bleeding and blood product usage, it would seem that antifibrinolytics offer one way to do this safely.In the current manuscript, Sussman et. al. retrospectively analyze 78 cardiac surgical patients who had an intraoperative TEG performed with the goal of describing the distribution of fibrinolytic phenotypes in this population8. Forty five percent demonstrated physiologic fibrinolysis, 32% hypo fibrinolysis, and 23% hyperfibrinolysis (LY30 <0.8%, 0.8-3%, >3%). Forty seven percent received antifibrinolytic agents. Outcomes including “morbidity” and time with chest tube were higher in those who received antifibrinolytics. This is a perhaps the first study of its kind to describe the prevalence of hyperfibrinolysis in cardiac surgical patients as measured by point of care testing. It is also a very relevant study in an era in which the benefits of targeted therapy for coagulopathy are increasingly recognized.The current data suggests that half of patients undergoing cardiac surgery demonstrate physiologic fibrinolysis and a third demonstratehypo fibrinolysis (a theoretically pro thrombotic state)8. The worse outcomes seen in patients receiving antifibrinolytics suggests that their administration in the setting of a potentially prothrombotic state was to blame. However, several limitations merit mention. It appears that TEG is not routinely performed on all patients. The population under study may therefore reflect one undergoing more extensive surgery with more coagulopathy in whom TEG is more likely to be performed. Since the actual timing of the TEG is not detailed, the true baseline fibrinolytic phenotype of patients treated with antifibrinolytics is not clear as the TEG results may have been obtained after the initiation of antifibrinolytics. Furthermore, while surgical procedures performed weren’t delineated, patients receiving antifibrinolytics more frequently had “valve disease” and “heart failure” and underwent on-pump surgery. Patients receiving antifibrinolytic therapy were therefore sicker and likely underwent more extensive on-pump valve surgery, while patients who did not receive antifibrinolytics were most likely undergoing off-pump coronary bypass surgery. Finally, the increased “morbidity” in patients receiving antifibrinolytics appear to be bleeding related (thrombotic complications were not listed separately). Perhaps additional antifibrinolytics were needed.The authors are to be commended for recognizing a lack of complete understanding of coagulation in the cardiac surgical population and attempting to determine the benefit of targeted antifibrinolytic therapy. Any time a practice is performed indiscriminately, there is room for improvement. However, before we contemplate altering an evidence-based practice that reduces bleeding, we need to demonstrate a benefit for such a change. Not all bleeding is purely surgical or purely medical; there is overlap. Few areas of medicine highlight how much art prevails over our current scientific understanding. Too many times since the introduction of point-of-care testing, the surgeon and anesthesiologist battle over the merits of administering blood products to a clinically bleeding patient with a normal coagulation profile. Targeted correction of coagulopathy is conceptually attractive, but the reality is not as clearly defined. Reductions in bleeding seen with antifibrinolytics occur both in on-pump and off-pump surgery which should be enough proof to continue its application until better evidence and understanding emerges6. Certainly, there is more work to be done, but with regard to antifibrinolytics it seems fitting to recognize: If it ain’t broke, don’t fix it.REFERENCESAbdelmotieleb M, Agarwal S. Viscoelastic testing in cardiac surgery. Transfusion 2020;60:52-60Harvey R, Salehi A. Con: Antifibrinolytics should not be used routinely in low-risk cardiac surgery. J Cardiothorac Vasc Anesth 2016;30:248-251Gielen C, Brand A, van Heerde W, Stijnen T, Klautz R, Eikenboom J. Hemostatic alterations during coronary artery bypass grafting. Thromb Res 2016;140:140-146Slaughter T, Faghih F, Greenberg C, Leslie J, Sladen R. The effects of ε-aminocaproic acid on fibrinolysis and thrombin generation during cardiac surgery. Anesth Analg 1997;85:1221-6Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper J, Marasco S, McNeil J, Bussieres JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 2017;376:136-48Zhang Y, Bai Y, Chen M, Zhou Y, Yu X, Zhou H, Chen G. The safety and efficiency of intravenous administration of tranexamic acid in coronary artery bypass grafting (CABG): a meta-analysis of 28 randomized controlled trials. BMC Anesthesiol 2019;19:104Kasrki J, Djaiani G, Carroll J, Iwanochko M, Seneviratne P, Liu P, Kucharczyk W, Fedorko L, David T, Cheng D. Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: A prospective randomized controlled clinical trial. J Thorac Cardiovasc Surg 2005;130:309-14Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg in press
Prediction scores and metrics are being increasingly utilized throughout the fields of cardiothoracic and congenital cardiac surgery to identify areas for perioperative optimization or guide therapeutic intent. Here, we review a novel submission by Yang and colleagues to the Journal of Cardiac Surgery identifying preoperative factors which predict adverse postoperative outcomes from cone reconstruction for Ebstein's anomaly.
The use of radial artery (RA) grafts for coronary bypass surgery has recently gained newer attention since it has been associated with significant reduction in the risk of midterm cardiac events. Surprisingly the use on the RA graft as second ‘best’ conduit has been limited among the surgical community. There may be several explanations for the little popularity of the RA graft; one of the reasons that could prevent surgeons to include the RA in the daily surgical armamentarium it is that patients with RA grafts may require postoperative calcium-channel blocker (CB) therapy. Due to the thick muscular wall, it seems possible that the RA would needs CB in order to prevent spasm and ameliorate patency. CBs are, however, associated with important side effects; also they have hypotensive effect that can hamper the use of other therapy such as beta-blocker or angiotensin-converting enzyme inhibitors. The evidence supporting the use of CB after RA graft (either in the early phase or as chronic calcium-blocker (CCB)) is weak. A the post-hoc analysis from the ‘RADIAL’ (Radial Artery Database International ALliance), showed that in patients with RA, the use of CB for at least 12 months was associated with better clinical and angiographic outcomes at mid-term follow-up, but confounders and bias may be responsible for the reported findings (as healthier patients are more likely to tolerate CB) . This review aims to summarize current evidences available on the topic and to serve as benchmark for evidence-based decision-making for CB prescription after RA grafting.
Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) However AF recurrence after a single ablation procedure is common and often attributed to ineffective lesion delivery during PVI. In this issue of the Journal of Cardiovascular Electrophysiology, Chen et al reported their experience with 122 patients who underwent an ablation index-high power (AI-HP) strategy RF ablation for AF using 50W power, targeting AI values of 550 on the anterior left atrium (LA), 400 on the posterior wall and inter-lesion distance (ILD) 6mm. They achieved 1st pass PVI in 96.7% of cases, mean RF time was 11.5min and total procedure time was only 55.8min. All patients had 72h-Holter monitor and trans-telephonic follow up. They reported 89.4% arrhythmia free survival among patients with paroxysmal AF and 80.4% among patients with persistent AF at 15-month follow up. Sixty (49%) patients had luminal esophageal temperature (LET) >390C out of which 3 (2.5%) had asymptomatic endoscopic esophageal erosions/erythema. Four (3%) patients had clinically apparent steam pops during ablation with no adverse clinical sequela. While AI-HP guided RF ablation may be an attractive strategy for PVI that likely reduces procedure times and probably has comparable efficacy to conventional ablation settings, its safety requires further evaluation. Feedback from the ablated tissue may need to be incorporated into optimized ablation energy parameters to further improve outcomes.
CABG (Coronary Artery Bypass Grafting) has been the treatment of choice for coronary artery disease for over 50 years and is the most common cardiac surgery procedure performed. Traditionally CABG was performed with the use of cardiopulmonary bypass and the use of cardioplegia to allow the surgeon to operate on a stable field. In the mid-1990s, interest emerged in performing CABG without the use of cardiopulmonary bypass - off pump CABG. This invited commentary focuses on sharing our experience with Low Ejection fraction off-pump CABG and why this approach could be beneficial to this patient population.
Commentary:When Starting a MICS Program, Don’t Assume Excellence: Prove It!Rachel Eikelboom MD1,2, Rashmi Nedadur MD3,Roberto Vanin Pinto Ribeiro MD3, Bobby Yanagawa MD PhD31 Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada2 Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada3 Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, CanadaCorresponding author:Bobby Yanagawa MD, PhD, FRCSC Program Director, Division of Cardiac Surgery, University of Toronto Assistant Professor, Division of Cardiac Surgery, St. Michael’s Hospital 30 Bond Street, 8th Floor, Bond Wing Toronto, ON M5B 1W8 Canada Tel: 416 864 5706 Fax: 416 864 5031 Email: firstname.lastname@example.orgWord count: 430Conflict of interest: The authors have no conflict of interest and have not received any funding.Central Figure:
Introduction: Several homeostatic changes like an increase in sympathoadrenal response and oxidative stress occur in hypoglycemia. As a result of these findings, an increase in inflammation and pre-atherogenic factors is observed and these changes may lead to endothelial dysfunction. Aim: Our study aims to reveal possible cardiac risks (systolic-diastolic functions and endothelial dysfunctions) in patients who have applied to the emergency department with hypoglycemia. Methods: This cross-sectional, case-control study included 46 hypoglycemia patients who admitted to the emergency with symptoms compatible with hypoglycemia and diagnosed with hypoglycemia and 30 healthy volunteers. All patients were evaluated with baseline echocardiography, tissue-doppler imaging(carotid and brachial artery). Also, the fasting blood tests of the patients referred to the internal medicine department were examined. Results: There were no differences between the groups regarding age, weight, body mass index, and systolic blood pressure. Total cholesterol, LDL, HDL, Vitamin B12, TSH, and fasting blood glucose levels were similar in the groups’ blood tests (all p values>0.05). We observed a statistically significant decrease in diastolic dysfunction parameters: E/A and E/e’ ratios (respectively, p=0.020 and 0.026). It was shown that insulin resistance was influential in forming these considerable differences. The patient group observed that the carotid intima-media thickness was more remarkable(p=0.001), and the brachial flow-mediated dilatation value was smaller(p=0.003), giving an idea about endothelial functions.